Name of Policy: Document Management System
Policy Number: 3364-107-316
Department: Pathology-Laboratory
Approving Officer: Chief Executive Officer - UTMC
Director, ClinicalResponsible Agent: Pathology/Hematopathology
Administrative Director, Lab
Scope: Pathology-Laboratory
ilin^m I' ' " ' 1 N I Y I R M 1 V or
Wjl TOLEDO
Effective Date: 2/20/2017
Initial Effective Date: 3/30/2005
New policy proposal X Minor/technical revision of existing policyMajor revision of existing policy Reaffirmation of existing policy
(A) Policy Statement
All laboratory documents are to be kept in an organized manner consistent with CAP standards.
(B) Purpose of Policy
To ensure consistent standards of practice concerning maintenance of laboratory documents.
(C) Procedure
1. Documents are written by appropriate staff.
2. Approval authority:a. Medical Director signs and authorizes all new and revised policies.b. Administrative Director, Lab Managers, Coordinators, Supervisors and/or designee may do the
mandatory review of policies and procedures every two years.
3. Staff reviews relevant policies and procedure annually, with records maintained as part of annualcompetency.
4. Policy and Procedure locations:a. Administrative policies are located at this link: http://utoledo.edu/policies/.b. Pathology Handbook is located on the Clinical Portal.c. Clinical procedure and policy manuals are located in each section for the clinical laboratory as
appropriate.d. Document control files are located on the common "Z" drive.e. Each department maintains their document control files and updates as necessary.
5. Obsolete method procedures are retained for a minimum of two years.
6. Medical director must initially approve all procedures. Supervisory staff, medical director, or designee mustreview each procedure at least every two years. All changes must be documented on the master copy. Allchanges must be signed and dated by appropriate personnel.
Policy 3364-107-316Document Management SystemPage 2
Approved by:
^ -'•:•"•>Robert L. Booth, Jr., M.D. DateAssociate ProfessorDirector, Clinical Pathology/Hematopathology
^x-^^Z "yf> S±^r± ^ /M^^4 ^OI^TLDaniel Barbee, RN BSN, MBA DateChief Executive Officer-UTMCReview/Revision Completed By:
Cynthia O 'Connell - Administrative Director - Lab
Policies Superseded by This Policy: Q-l 1-B
Review/Revision Date:3/31/20059/30/20059/18/20069/14/20076/10/20085/1/20113/1/20132/20/2017
Next Review Date: 2/20/20 1 9